Frail, older persons residing in nursing homes are a vulnerable population. Often, these patients are disabled, cognitively impaired, and financially impoverished. Nationally, one in five persons die in a nursing home. Research has shown that between 33 percent and 83 percent of patients have ongoing pain that impairs mobility, results in depression, and diminishes quality of life. A recent study from the Center for Gerontology and Health Care Research at Brown University reported that one in four of cancer patients discharged from an acute care hospital who were assessed to be in daily pain was not administered any analgesic medicine. The observed high rates of unrelieved pain are not based on a scientific controversy regarding pharmacological management. They are not based on patient preferences. Educational interventions and professional guidelines have not remedied this situation-far too many persons are still not receiving adequate palliation. An important step to improving the quality of care is raising health care providers' awareness of the opportunity to improve. The overall goal of this project is to develop and validate an efficient measurement strategy for accountability and quality improvement of pain management in nursing homes. Potential sources of data include interviews with nursing home residents or a surrogate in the case of nursing home residents with severe dementia and the computerized Minimum Data Set (MDS). We propose to develop and validate a brief, survey of nursing home residents or their loved ones concerning the quality of pain management through focus groups, cognitive interviews, and conducting tests of reliability and construct validity (Specific Aim 1a). Interviews with the patient or family will utilize the methodology of Patient-Centered Reports as applied in the Consumer Assessment of Health Plan Study. Because of the high burden of cognitive impairment in nursing home residents, we will examine the validity and potential bias of relying on a surrogate to examine the quality of pain management (Specific Aim II). While the MDS pain assessment instrument reliability has been examined with trained, research nurses, a third effort will examine the reliability and validity of the MDS in its "real world" application (Specific Aim 1b). Based on the collected information on reliability, validity, and ease of data collection, we will formulate an efficient and valid strategy to examine the quality of pain management for frail, older persons residing in nursing homes.